"...you don’t want to be known as a place where babies die”
It is, of course, far worse than that. (GW)
By Timothy Williams
New York Times
October 14, 2011
PITTSBURGH — Amanda Ralph is the kind of woman whose babies are prone to die. She is young and poor and dropped out of school after the ninth grade.
But there is also an undeniable link between Ms. Ralph’s race — she is black — and whether her baby will survive: nationally, black babies are more than twice as likely as white babies to die before the age of 1. Here in Pittsburgh, the rate is five times.
So, seven months into her first pregnancy, Ms. Ralph, 20, is lying on a couch at home as a nurse from a federally financed program listens to the heartbeat of her fetus.
The unusual attention Ms. Ralph is receiving is one of myriad efforts being made nationwide to reduce the tens of thousands of deaths each year of infants before age 1. But health officials say it is frequently disheartening work, as a combination of apathy and cuts to federal and state programs aimed at reducing infant deaths have hampered progress, with dozens of big cities and rural areas reporting rising rates.
The infant mortality rate in the United States has long been near the bottom of the world’s industrialized countries. The nation’s current mark — 6.7 deaths per 1,000 live births — places it 46th in the world, according to a ranking by the Central Intelligence Agency.
African-Americans fare far worse: Their rate of 13.3 deaths per 1,000 is almost double the national average and higher than Sri Lanka’s.
Precisely why the black infant mortality rate is so high is a mystery that has eluded researchers even as the racial disparity continues to grow in cities like Pittsburgh, Los Angeles and Boston.
In Pittsburgh, where the unemployment rate is well below the national average, the infant mortality rate for black residents of Allegheny County was 20.7 in 2009, a slight decrease from 21 in 2000 but still worse than the rates in China or Mexico. In the same period the rate among whites in the county decreased to 4 from 5.6 — well below the national average, according to state statistics. Figures for the past two years, which are not yet available, have most likely increased the gap significantly, county health officials said.
While Pittsburgh’s struggles are illustrative of problems in other cities, it also faces its own particular issues, including the county’s privatization of many of its health care services over the years.
With the county taking a reduced role, Healthy Start, a federally financed national nonprofit group, is now responsible for Pittsburgh’s most vulnerable pregnant women. None of its $2.35 million budget, much of which is used for 6,000 annual home visits, comes from the county. The group’s budget has not increased since 1997.
Even with its high-risk clients, Healthy Start has had success: in 2007 there were no child deaths among its participants countywide. The numbers though, have begun to creep up, and in 2010 the mortality rate among participants was 13.9.
“As a city you want to be known for your football and baseball teams, but you don’t want to be known as a place where babies die,” said Cheryl Squire Flint, who leads the group’s Pittsburgh branch.
That, however, is precisely what is happening.
“We have one of the top schools of public health and one of the top schools of medicine, yet the problem is hidden,” said Angela F. Ford, executive director of the University of Pittsburgh’s Center for Minority Health, which works to address health disparities.
Recent studies have shown that poverty, education, access to prenatal care, smoking and even low birth weight do not alone explain the racial gap in infant mortality, and that even black women with graduate degrees are more likely to lose a child in its first year than are white women who did not finish high school. Research is now focusing on stress as a factor and whether black women have shorter birth canals.
“It is truly one of the most challenging issues, because it is multifactorial,” said Dr. Garth Graham, a deputy assistant secretary in the Office of Minority Health at the Department of Health and Human Services. “And nationally, the disparity has remained despite our best efforts.”
Dr. Bruce W. Dixon, Allegheny County’s health commissioner for the last 19 years, said the primary cause for the growing disparity is an inequity in health care access.
“It’s not medical care, it’s social issues,” he said.
Dr. Dixon, who is white, has supported shifting much of the county’s previous health care burden to private providers like Healthy Start because he believes they are able to deliver medical services more effectively and at lower cost. He said his department’s mainly white, middle-age bureaucrats had failed to adequately reduce mortality rates, which he blamed on their inability to communicate effectively. Black residents, however, say the disparity is not perceived as a problem because it is limited to a marginalized group.
“It wasn’t affecting whites, so no one really cared because they didn’t know about it,” said Wilford Payne, who operates 11 community health centers in Pittsburgh.
Some here say black women are reluctant to seek prenatal care because they fear they will be mistreated.
“People who need the services are the ones least likely to get them,” said Dannai Harriel, 34, who was a Healthy Start client when she became pregnant at 17, and later worked for the organization.
Ms. Ralph, who expects to deliver a healthy baby girl around Christmas, said when she first found out she was pregnant she hid her face under a blanket and lay motionless on her living room floor.
But after meeting with Healthy Start nurses and outreach workers, who provide as much psychological support as health care, Ms. Ralph said, she became excited about having a child.
Her living room floor is now full of little pink boxes and brightly colored bags filled with lotions and candles — party favors she bought for guests to her forthcoming baby shower. Among the guests will be her obstetrician. While Ms. Ralph is doing well, Healthy Start workers still have concerns. Because she drinks too much soda and does not appear to be eating nutritious foods, Ms. Ralph has gained 50 pounds during her pregnancy and now weighs 181. She has been told that overweight women have a higher risk of complications during pregnancy.
But Ms. Ralph has few healthy food options. The nearest grocery store is a 15-minute walk from the home she shares with her mother. Local shops sell little more than soda, chips and candy. Ms. Ralph, who said she was eating plenty of fruits and vegetables, acknowledges a taste for tacos and comfort foods.
“I can’t help it,” she said. “I love my mama’s cooking.”
At the end of a 45-minute visit with Dradia Toblin, her caseworker, and Clara Brown, a registered nurse, she was told that her baby — whom she has decided to name Kaylah — is now able to open her eyes and practice her breathing.
“You are doing a good job,” Ms. Brown tells her. “You are growing a good baby.”
Others, however, may not be so fortunate, and without focused attention, infant deaths in the county — now more than 100 each year — may continue to rise, advocates say.
“We’re not looking and thinking long-term,” said Carmen Anderson, who previously led Healthy Start and is now a senior officer with the Heinz Endowments of Pittsburgh. “We are in day-to-day crisis mode. Sometimes those who scream the loudest get the attention. And there’s no screaming.”